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HARVARD    MEDICAL    SCHOOL. 


Theory  and  Practice. 


1900-1901. 


BOSTON : 

THOMAS  GROOM  &  COMPANY. 

1900. 


Copyright,  1900, 
By  Elbridge  G.  Cutler. 


INDEX. 


PAGE 

The  History 5 

General  Examination  of  the  Body 8 

Urine ii 

Blood 12 

Sputum 13 

Stomach  Contents 16 

FiECES     . ^9 

Apparatus  and  Chemical  Reagents 21 


V5 


Digitized. by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/theorypractice1900harv 


The  History. 


A^RITE  down  first  the  name  of  the  patient,  married  or 
single,  age,  residence  and  birthplace  (malaria,  hydatid, 
etc.),  occupation  (eye  strain,  writer's  cramp,  stone  cutter, 
painter,  etc.)  and  the  date  on  which  he  is  seen. 

The  patient  should  be  questioned  first  about  the  present 
illness,  whether  his  disease  is  acute  or  chronic.  Having  ob- 
tained a  general  idea  of  its  nature,  the  family  history  and 
personal  history  should  be  taken  and  the  present  illness 
obtained  in  detail.  If  the  patient  is  very  ill,  depend  largely 
on  the  friends  for  data  and  obtain  other  necessary  information 
during  later  visits.  Avoid  embarrassing  questions  in  the  pres- 
ence of  a  third  person. 

As  a  rule,  let  the  patient  tell  his  story,  simply  guiding  his 
narrative  into  profitable  channels.  Avoid  leading  questions. 
Do  not  be  misled  by  his  medical  expressions.  Lay  diagnoses 
of  meningitis,  influenza,  gastric  catarrh,  rheumatism  and  dys- 
entery are  untrustworthy  and  should  be  independently  diagnos- 
ticated by  the  doctor.  Note  the  difference  between  chilliness 
and  a  true  chill.  Sometimes  the  history  obtained  is  incorrect 
because  of  the  dulness  of  the  patient,  either  natural  or  due  to 
the  disease.  Here  repeated  questioning  alone  secures  a  satis- 
factory  result. 

Histories  obtained  from  hospital  patients  are  proverbially 
unreliable.  These  people  are  for  the  most  part  ignorant,  over- 
worked and  unobservant.  No  matter  what  methods  are  em- 
ployed to  obtain  the  histories,  it  is  well  to  be  sceptical  about 
their  accuracy,  especially  when  the  physical  examination  fur- 
nishes contradictory  evidence.  In  children  this  is  even  more 
important.  Most  children  are  unable  to  furnish  information 
about  themselves,  and  their  histories  must  be  obtained  from 
people  in  charge. 


Children  usually  answer  questions  incorrectly  which  concern 
their  present  sensations.  This  may  be  from  fear,  embarrass- 
ment, misunderstanding,  etc.  Information  obtained  in  this  way 
often  leads  to  incorrect  diagnoses. 

General  questions  as  to  heredity  are  equally  unsatisfac- 
tory. Definite  interrogations  must  be  put,  but  where  one  has 
fears  for  the  truthfulness  of  an  answer,  the  information  must  be 
obtained  in  a  more  roundabout  way,  —  e.  g.,  such  patients  will 
agree  to  a  parent  having  had  "  nerve  trouble "  or  "  brain 
trouble "  who  might  deny  the  presence  of  family  insanity. 
Tubercular  ancestry  is  important,  but  it  is  also  desirable  to 
know  whether  the  relative  died  years  ago  or  has  lived  in  contact 
with  the  patient. 

In  the  personal  history  illnesses  are  often  forgotten,  so  it  is 
well  to  mention  specifically  the  infectious  diseases,  —  chorea, 
rheumatic  fever,  etc.  As  a  rule,  one  can  get  a  more  satisfactory 
answer  regarding  habits  toward  the  end  of  a  visit  than  at  the 
beginning,  but  in  no  case  must  one  neglect  inquiries  concerning 
alcohol,  tobacco,  tea,  coffee,  times  and  methods  of  eating  and 
sleeping  and  venereal  disorders.  In  this  last  matter,  indirect 
questions  are  often  best.  A  patient  will  admit  having  had 
a  "strain"  or  frequent  and  scalding  urine,  who  will  deny 
gonorrhea.  On  the  other  hand,  inquiries  about  pregnancy, 
catamenia,  etc.,  should  be  simple  and  straightforward,  not  sug- 
gested in  a  roundabout  prudish  manner. 

Present  Illness.  The  first  question  should  always  be 
"  How  long  have  you  been  ill?"  "  How  long  in  bed  ?  "  and  the 
next,  "What  was  the  first  symptom?"  -  "the  next  symptom?" 
and  so  on  tracing  the  course  of  the  disease.  The  patient's 
answers  suggest  other  subjects  important  in  the  differential 
diagnosis  and  it  is  here  the  doctor  or  student  shows  the  extent 
and  accuracy  of  his  medical  knowledge  by  asking  enough,  but 
not  too  much.  Individual  symptoms  ( e.  g.  abdominal  pain, 
etc. )  should  be  analyzed  according  to  their  mode  of  onset, 
frequency,  duration,  character  and  severity.  Always  consider 
the  temperamen^t  of  the  patient  when  statements  are  made 
dealing  with  pain,  discomfort  or  fatigue.  The  following  ques- 
tions are  very  valuable  in  summing  up  the  case :  — 

"  How  long  ago  did  you  call  yourself  perfectly  well?" 

"  When  did  you  stop  work  ?  " 

"What  one  thing  troubles  you  most? " 

"  If  5^ou  were  cured  of  x,  y  and  z  would  you  consider  your- 
self well?" 


It  is  desirable  to  include  in  the  history  a  few  general  ques- 
tions concerning  the  appetite,  the  bowels  (daily  or  otherwise), 
ability  to  sleep  and  work  (as  an  index  of  the  sufferings),  also 
questions  about  the  functions  of  the  various  systems  not  in- 
cluded in  the  patient's  statement. 

{e.g.)  Digestive.       Nausea,  discomfort  after  eating, 

vomiting,  bowels. 
Respiratory.  Cough,  sputum,  pain  in  chest. 
Circulatory.    Dyspnoea,  palpitation,  oedema. 
Nervous.         Headache,  convulsion,  paralysis. 
Urinary,  {a)  Renal:  headache,  amount  of  urine, 
oedema. 
{b)   Vesical:  dysuria,  anuria,  frequent 
micturition. 

The  mere  fact  that  a  patient  vomits  or  expectorates  is  of 
little  value.  The  amount,  color,  presence  of  blood  and  mucus 
are  all  important. 


*^General  Examination  of  the  Body. 


General  Nutrition.  Muscular  development,  size,  weight, 
figure,  attitude,  decubitus. 

Skin  and  Mucous  Membranes.  Pale,  flushed  (hectic), 
cyanosed,  pigmented  (jaundiced,  bronzed  skin  and  buccal 
mucous  membrane).  Cold,  hot,  dry,  moist,  satiny  (alcoholic), 
rough.  Scars,  eruptions  (Koplik's  sign),  oedema,  emphysema, 
calluses,  rheumatic  nodules. 

Temperature.     Mouth,  axilla  or  rectum. 

Pulse.  Rate,  tension  for  compressibility),  volume  (or 
wave),  rise  (or  shape  of  wave) ;  compare  radials.  Capillar}^ 
pulse.     Water-hammer  pulse  (Corrigan). 

Arteries:  Size,  abnormal  course,  arterio-sclerosis,  auscul- 
tation of. 

Veins :  Size,  pulsation  (systolic  or  slow  presystolic,  fill 
from  below  ?)  auscultation  of,  varicosity. 

Respiration.  Frequency,  painful,  shallow,  costal,  diaphrag- 
ma.tic.     Dyspnoea  (expiratory,  inspiratory,  Cheyne-Stokes). 

Glands.  Suboccipital,  mastoid,  parotid,  sub-maxillary, 
superficial  and  deep  cervical,  supaclavicular,  axillary,  epitro- 
chlear.  inguinal  (bronchial,  mediastinal,  mesenteric). 

Glands  are  either  small,  large,  hard,  soft,  fluctuating  (adhe- 
rent or  non-adherent),  discrete  or  conglomerate. 

HEAD. 

Size,  shape  (rachitic,  hydrocephalic,  microcephalic),  fonta- 
nelles,  tender  spots,  cranio  tabes,  hair. 

Facies.  Placid,  stupid,  anxious,  pinched,  puffy,  adenoid, 
alcoholic,  heimatrophic,  myxoedematous,  acromegalic,  mask- 
like (Paralysis  Agitans). 

Eyes.  Pupils  (size,  equality,  shape,  reflexes,  Argyll-Rob- 
ertson), ophthalmoplegia  (strabismus,  ptosis),  nystagmus, 
conjunctivitis,  exophthalmos;  vision  (condition  of  retina,  hemi- 
anopsia, amaurosis).     Oedema  of  lids  (Pertussis), 


*  Physical  examination  is  not  dependent  upon  a  knowledge  of  the  patient's 
previous  history  and  present  sensations.  It  is  a  good  plan,  therefore,  for 
students  to  examine  the  patient  before  the  history  is  taken.  The  examination 
will  be  made  more  systematically  and  accurately  in  this  way. 

8 


Nose.     Deformities,  hypertrophies,  tumors. 

Lips.     Color,  herpes,  fissures,  hare-lip. 

Breath.  Sweet,  foul,  alcoholic,  uraemic ;  acetone,  gas 
poisoning. 

Tongue.  Pale,  red,  cyanosed,  dry,  moist,  coated,  fissures, 
smooth,  rough,  indented  by  teeth,  geographical  tongue,  devia- 
tion, salivation,  stomatitis,  leucoplakiabuccalis,  mucous  patches. 

Gums.  Color,  spongy,  lead  line  (use  lens  and  insert  a  slip 
of  white  paper  behind  gum),  sordes,  scurvy. 

Teeth.     Number,  carious,  deformed  (Hutchinson). 

Pharynx.  Tonsils,  adenoids,  membrane,  elongated  or 
oedematous  uvula,  retropharyngeal  abscess,  pharyngeal  re- 
flexes and  paralyses  (tabes,  diphtheria). 

Larynx.     Voice,  laryngoscope. 

Ear.  Hearing,  tympanum,  mastoid  tenderness,  tophi,  stig- 
mata. 

Neck.  Venous  fulness,  pulsations,  tracheal  tug,  parotid, 
thyroid,  high  spinal  abscess,  spinal  curvature,  torticollis. 

CHEST. 

Inspection.  Size,  form  (barrel  chest,  paralytic  chest, 
pigeon  breast,  rosary),  symmetry  and  comparative  mobility. 
Rate  and  character  of  respiration,  Litten's  phenomenon. 
Location  and  character  of  cardiac  movements.  Apex  beat, 
retraction  (Broadbent's  sign).  Pulsation  (aneurism,  aortic 
regurgitation,  uncovered  or  displaced  heart. 

Character  of  cough  —  dry,  loose,  constant,  paroxysmal. 

Palpation.  Rales,  tactile  fremitus,  apex  beat,  thrills,  fric- 
tion, pulsation,  accentuated  heart  sounds,  tender  points. 

Percussion.  Pulmonary  resonance,  mobility  and  location 
of  lung  and  heart  borders.  Size  and  position  of  heart.  Respir- 
atory percussion.     Sense  of  resistance. 

Auscultation.  Respiration,  rales,  voice  sounds,  friction 
rub,  succussion.  Heart  sounds,  diminution,  accentuation, 
rhythm,  doubling.  Murmurs:  in  erect  and  dorsal  position, 
time,  character,  transmission,  relation  to  heart  sounds. 

ABDOMEN. 

Inspection.  Size,  shape,  abdominal  walls  (thickness,  ten- 
sion, striie,  umbilicus,  superficial  veins,  peristalsis),  herniae. 

Palpation.  Position,  outline  and  mobility  of  liver,  gall 
bladder,    spleen,    kidneys,  stomach,  bladder  (and    pancreas)  : 


tumors  (see  below),  relation  to  inflated  colon,  stomach  and  to 
other  organs.  Local  tenderness  (superficial  or  deep)  and  resist- 
ance, friction,  fluctuation  wave,  succussion,  pulsation  (aorta), 
enteroptosis. 

Percussion.  Outline  of  liver,  gall  bladder,  spleen,  stomach, 
bladder,  uterus,  resonance  of  tumors,  gas,  ascites  (movable 
dulness),  curve  of  dulness  (ascites,  cyst). 

NERVOUS   SYSTEM. 

1.  Mental  State.  Intelligence.  Psychoses,  hypochon- 
driasis, apathy,  stupor. 

2.  Motion. 

1.  Paresis  or  paralysis. 

2.  Gaits  :  spastic,  ataxic. 

3.  Reflexes :  pupillary,  knee  jerk,  ankle  clonus,  plan- 

tar (Babinski),  Kernig's  sign, 

4.  Ataxia  (Romberg),  localized  and  general  convul- 

sions, tremor,  chorea,  athetosis,  fibrillation. 

5.  Electrical  Reactions. 

3.  Sensation. 

1,  Tactile,  pain,  temperature. 

2,  Delay,  paraesthesias,  muscle  sense. 

3,  Special  sense  :  sight,  hearing. 

4.  Speech  Disturbance.     Aphasia,  paralysis. 

5.  Trophic  Disturbances. 

6.  Sphincters  and  Sexual  Power. 


Extremities.  Clubbed  fingers,  flat-foot,  oedema,  tender- 
ness (neuritis,  trichinosis). 

Bones  and  Joints.  Redness,  tenderness,  swelling,  crepi- 
tus, mobility,  epiphyses,  deformity,  (spinal  curves,  bow-legs, 
arthritis  deformans,  Heberden's  nodes). 

Muscles.  Atrophy,  hypertrophy,  tone  (firm,  flabby),  paraly- 
sis, spasm,  tremor,  contracture,  fibrillation. 

Rectum.  Prolapse,  fissure,  fistula,  abscess,  piles,  impacted 
faeces,  stricture,  tumors  (prostate,  vesiculae  seminales),  intus- 
susception. 

Genitals.  Urethra,  character  of  stream,  discharge,  glans 
penis,  testes,  vagina,  uterus,  tubes,  ovaries,  tumors. 

Tumors.  Location,  shape,  size,  color,  consistency,  surface, 
tenderness,  mobility  (by  respiration,  by  hand),  dulness,  pulsa- 
tion, relation  to  organs. 

10 


Urine. 

Amount  in  twenty-four  hours.  Color.  Odor.  Reaction. 
Specific  Gravity.     Sediment.     Turbidity.     Shreds. 

Albumin.  Heat  —  boiling  upper  half  of  urine  in  test-tube  ; 
observe  if  precipitate  disappears  on  adding  dilute  acetic  acid. 
If  a  precipitate  appears  on  heating  and  disappears  on  boiling, 
suspect  albumose.  Estimate  the  per  cent,  of  albumin  by  the 
nitric  acid  test. 

Sugar.  I.  Fehling's  Test  lo  c.  c.  of  Fehling's  solution 
are  reduced  by  0.05  gram  glucose. 

2.  Fermentation  Test  using  yeast.  Difference  in  specific 
gravity  before  and  after  complete  fermentation,  muliplied  by 
0.23  gives  percentage  of  sugar. 

Acetone.  To  one-sixth  of  a  test-tube  of  urine  add  a  crystal  of  sodium  nitro- 
prusside.  Make  strongly  alkaline  with  NaOH.  Shake.  Addition  of  glacial 
acetic  acid  gives  purple  color  to  foam. 

Diacetic  Acid.  Add  strong  aqueous  solution  of  ferric 
chloride.     A  Burgundy  red  shows  presence  of  diacetic  acid. 

B.  Oxybutyric  Acid.  If  ferric  chloride  reaction  is  strongly  positive, 
B.  oxybutyric  acid  is  probably  present. 

Urea.     Amount   in   twenty-four   hours.     Squibb's   method. 

Bile.     I.     Shake  up  and  look  at  foam. 

2.  Iodine  test.  (Tr.  iodine,  i ;  alcohol,  8.)  Pour  on  top 
of  urine.     A  green  ring  at  border  of  two  fluids  shows  bile. 

Diazo.  Saturated  solution  sulphanilic  acid  in  H  CI.  Sodium 
nitrite,  0.5  per  cent.  Ammonia.  To  4  c.  c.  sulphanilic  acid  in 
H CI  add  a  few  drops  sodium  nitrite.  Now  add  equal  part  of 
urine.     Shake  and  add  ammonia.     A  carmine  color  shows  diazo. 

Chlorides.     Ag  NO3. 

Sediment.  Macroscopic  and  microscopic  examination. 
Staining  for  tubercle  bacillus ;  see  sputum.  For  gonococcus, 
use  Gram's  stain. 

1.  Smear  cover  glass  as  thin  as  possible. 

2.  Anilin  oil-gentian-violet  (fresh). 

3.  Heat  to  steaming  point. 

4.  IKI  solution  thirty  seconds. 

5.  Decolorize  with  95  per  cent,  alcohol  until  alcohol  runs 
clear. 

6.  Wash  in  water. 

7.  Counterstain  with  saturated  aqueous  solution  Bismarck 
brown.  Diplococci  within  leucocytes  which  have  been  de- 
colorized by  Gram  and  have  taken  counterstain  of  brown  are 
gonococci. 

II 


Blood. 

{a)  Examination  of  fresh  blood  for  leucocytosis,  fibrin 
parasites,  Miiller's  bodies,  etc. 

(3)  Examination  of  stained  specimen.  Triple  stain  -|- 
Loffler's  Methylene  blue. 

Red  Corpuscles.  \^ariation  in  size  and  shape  (poikilocy- 
tosis).  Loss  of  color  (acromia).  Tendency  toward  a  general 
increase  or  decrease  in  size. 

XT       u        r   i  Normoblasts    )    in  one  or  more  stained  speci- 
Number  of  \  Megaloblasts,  |  mens. 

White  Corpuscles.  Estimation  of  number  of  white  cor- 
puscles. 

Differential  Count.     Leucocytosis:  — presence,  kind. 
Number  of  Basophiles  (lymphocytes  and  large  mononuclear) 
Neutrophiles. 
Oxyphiles  (eosinophiles). 
Myelocytes  (neutrophilic,  oxyphilic). 
(c)     Blood  count.     Number  of  red  corpuscles. 

"        "  white      " 
{d)     Color  estimation.     Haemoglobin  per  bulk  blood  {%). 

"     per  corpuscles  (color  index)^ 
{e)     Parasites.     Malaria.     Filaria. 
(/l     Serum  reaction. 
(^)     Coagulation  time. 


12 


Sputum. 

Sputum  is  sometimes  very  difficult  to  obtain  for  examination, 
especially  in  the  case  of  young  children.  If  a  cotton  stick  is 
inserted  into  the  pharynx  it  causes  coughing,  and  sputum  com- 
ing from  the  trachea  may  be  wiped  out  upon  the  cotton  before 
it  can  be  swallowed.  Swallowed  sputum  may  be  obtained  by 
stomach  washing. 

Orig-in.  May  be  from  mouth,  nose,  pharynx,  larynx,  lung 
(or  stomach),  one  or  more  or  all. 

Amount  expectorated  in  twenty-four  hours  may  vary 
within  wide  limits,  —  small,  as  in  beginning  tuberculosis  of  the 
lungs,  or  large,  as  in  chronic  bronchitis. 

Odor.  Ordinarily  there  is  no  odor  to  sputum.  Under  cer- 
tain circumstances,  however,  as  in  abscess  or  gangrene  of  the 
lung  the  odor  may  be  foetid  and  disagreeable. 


MACROSCOPIC  EXAMINATION. 

Inspection.     Sputum  may  be,  — 

(a)     Mucous :  viscid. 

{d)  Purulent :  seen  in  pure  form  only  in  perforation  into  the 
lung  or  bronchi  of  foci  of  pus  such  as  abscess  of  lung  or 
empyema. 

(c)  Muco-purulent:  most  common  form  and  not  character- 
istic. 

{d)  Serous:  thin,  often  slightly  red  in  color  (blood)  and 
frothy ;  pathognomonic  of  oedema  of  the  lungs. 

(<?)     Nummular:  common  in  tuberculosis  of  the  lungs. 

{/)  Hemorrhagic  :  seen  especially  in  phthisis,  pneumonia, 
passive  congestion,  hemorrhagic  infarction,  aneurism  of  the 
aorta,  new  growths,  epistaxis  and  abscess  of  the  lung. 

{£■)     Tenacious  as  in  pneumonia  —  upset  the  cup. 

Color  may  be  — 

(a)     Rusty,  orange-juice  :  pneumonia. 

{d)     Grass-green:  pneumonia  combined  with  jaundice. 

13 


(c)  Black  or  gray  from  substances  inhaled,  such  as  carbon, 
or  colored  by  food  such  as  chocolate,  berries,  wine  or  tobacco. 

(d)  Reddish  yellow:  from  rupture  of  abscess  of  liver  into 
lung. 

MICROSCOPIC   EXAMINATION. 
Important  Constituents. 

(a)     Bacteria: 

1.  Bacilli  of  tuberculosis.  Pneumococcus.  Bacilli  of  influ- 
enza. Bacillus  mucosus  capsulatus.  Smegma  bacillus  (in  gan- 
grene.)    Streptococcus. 

2.  Fungi :  especially  of  actinomycosis. 

(6)  Elastic  fibres:  in  all  destructive  processes  in  the  lung; 
phthisis,  abscess,  gangrene. 

(c)     Fragments  of  lung  tissue  :  gangrene,  new  growth. 

Unimportant  Constituents. 

(a)     A  few  leucocytes. 

0)      A  few  red  blood  corpuscles. 

(c)  Alveolar  epithelial  cells,  often  containing  fat  and  carbon, 

(d)  Squamous  and  cylindrical  cells. 

(e)  Common  bacteria. 
(/)  Particles  of  food. 

IMPORTANT  TECHNICAL  METHODS. 

Tubercle  Bacilli.  Use  forceps  instead  of  platinum  wire  to 
pick  up  the  sputum.  If  tubercle  bacilli  are  not  found  in  the 
first  carefully  prepared  cover-glass,  get  a  fresh  specimen  from 
the  patient. 

1.  Sputum  should  be  thinly  spread  upon  the  cover-glass. 

2.  Ziehl's  Carbol-fuchsin,     Heat  to  steaming  point. 

3.  Czapelewski's  solution  until  decolorization  is  complete. 

4.  Wash  in  water. 

5.  Saturated  aqueous  solution  of  methylene-blue  to  the 
steaming  point, 

6.  Wash  in  water. 

7.  Examine  in  water  or  balsam. 

Elastic  Fibres,  i.  Boil  with  equal  parts  of  NaOH  in 
water  bath  till  clear. 

2.  Centrifugalize. 

3.  Examine  sediment  microscopically. 

Influenza  Bacillus,  i,  Loffler's  methylene-blue  to  steam- 
ing point. 

14 


2.  Wash  in  water. 

3.  Leucocytes   especially    to    be    examined    for    influenza 

bacilli. 

Capsule  Stain.     (Welch.)     i.     Glacial   acetic    acid    for   a 
few  seconds. 

2.  Drain    off     and    replace    with     anilin-oil-gentian-violet 
solution. 

3.  Wa.sh  in  2  per  cent.  NaCl,  and  mount  in  the  same. 


IS 


Stomach  Contents. 

Contents  of  Fasting  Stomach  removed  before  breakfast. 
Test  Breakfast  "        one  hour  after  eating. 

Vomitus :  number  of  hours  after  last  meal. 

Amount.         Color.  Odor.  Mucus.  Food.         Froth. 

Reaction.         Combined  H CI.      Total  free  HCl,  —  quantitative. 
Free  H  CI.       Lactic  acid.  Total  acidity,  —  quantitative. 

Food.     Fragments  of  Mucous  Membrane.     Blood.     Pus. 


Contents  of  Fasting-  Stomach  generally  obtained  in  the 
morning.  Stomach  should  be  empty  seven  to  eight  hours  after 
the  last  meal.  If  food  is  still  present,  it  is  a  sign  of  stasis.  A 
few  c.  c.  of  fluid  containing  free  HCl  are  of  no  consequence. 
They  may  be  due  to  the  irritation  of  the  tube.  Amounts  above 
50  c.  c.  of  gastric  juice  indicate  hypersecretion. 

Test  Breakfast  (Ewald)  consists  of  one  slice  of  bread 
and  a  glass  and  a  half  of  water.  At  the  end  of  one  hour  not 
over  100  c.  c.  should  remain  in  the  stomach.  Amounts  of 
150-300  c.  c.  imply  motor  insufficiency  or  hypersecretion.  In 
one  and-one-half  to  two  hours  the  stomach  should  be  empty. 

In  expression,  do  not  dilute  the  contents  with  water. 

Vomitus  to  be  examined  in  the  same  way  as  the  above. 
Free  HCl  may  be  absent  in  the  vomitus  and  yet  present  after  a 
test  breakfast. 


Amount.  See  above.  The  amount  of  vomitus  alone  may 
indicate  a  dilatation  of  the  stomach. 

Color.  Fresh  blood  is  suggestive  of  ulcer;  old  blood  (coffee 
grounds)  of  cancer.  A  few  fine  streaks  of  blood  are  of  no  sig- 
nificance. A  green  or  yellow  color  may  be  due  to  bile  or  mould. 
Avoid  mista.king  brown  fragments  of  food  for  blood. 

Odor.  The  odors  of  butyric  and  acetic  acids  are  character- 
istic. Marked  fermentation  gives  a  yeasty  odor,  (not  due  to 
lactic  acid).  There  is  a  peculiar  odor  associated  with  the 
presence  of  sarcince. 

t6 


Mucus.  In  "catarrh  of  the  stomach,"  mucus  is  so  abun- 
dant that  the  contents  can  be  poured  in  a  lump  from  one  beaker 
to  another.  Small  amounts  of  mucus  are  also  well  shown  in 
this  way.  Mucus  requiring  acetic  acid  for  its  demonstration  is 
of  no  significance.  Gastric  mucus  is  uniform  and  thoroughly 
mixed  with  food.     Mucus  from  the  mouth  is  not. 

Food.  See  Contents  of  Fasting  Stomach.  In  normal  con- 
tents, the  bread  is  in  fine  particles  and  looks  well  digested ;  in 
Achylia  Gastrica,  contents  differ  little  from  a  mixture  of  bread 
and  water.    Size  of  particles  is  also  an  index  of  mastication. 

Froth.  When  the  contents  separate  into  three  layers,  the 
lower  consists  of  the  undigested  portion  of  the  food,  the  middle 
of  a  rather  thin  liquid,  while  the  upper  is  made  up  of  froth  due 
to  gas  liberated  by  the  active  fermentation  in  which  are  mucus 
and  light  fragments  of  food.  Three  layers  are  characteristic 
of  dilatation  of  the  stomach. 


Reaction   due  to  free  HCl, 

combined  HCl  (acid  albumin,  etc.), 
acid  salts, 
organic  acids. 

Free  HCl.  Test  with  Gllnzburg's  Reagent  (phloroglucin, 
2  g. ;  vanillin,  i  g. ;  absolute  alcohol,  30  g.),  which  gives  a  posi- 
tive reaction  only  with  free  HCl.  Congo  red  (paper)  turns  blue 
in  the  presence  of  o.oi  per  cent,  free  HCL* 

Combined  HCl.  A  part  of  the  HCl  is  always  "combined" 
with  proteids.  Free  HCl  implies  combined  HCl.  Where  free 
HCl  is  absent,  combined  HCl  may  be  present  and  can  be 
tested  for  by  the  Ewald-Sjoqvist  method. 

Acid  Salts.  Acid  Phosphates  made  by  combination  of 
HCl  and  neutral  Phosphates  of  food.  In  clinical  work  these 
can  be  neglected. 

Organic  Acids. 

Lactic  Acid.  Stomach  contents  should  be  examined  at 
once,  as  lactic  acid  readily  develops  if  they  are  left  for  some 
time  in  a  warm  place.  Dilute  a  solution  of  Fe2  Cle  to  a  very 
faint  yelloAv  color  with  water.  Fill  the  concavities  of  two  test- 
tubes  with  this  solution,  using  one  for  comparison.     A  canary 


*  Org-anic  acids  and  acid  salts  also  produce  a  somewhat  similar  reaction 
with  Cong^o  red  (a  purple  or  broAvn),  but  in  solutions  more  concentrated  than 
are  ordinarily  found  in  stomach  contents.  Congo  is  therefore  not  an  absolute 
test  for  small  amounts  of  free  HCl  in  stomach  contents. 


yellow  color  on  addition  of  gastric  contents  suggests  lactic  acid 
with  considerable  certainty.  Negative  test  rules  out  lactic 
acid. 

When  test  is  positive  absolute  proof  is  obtained  by  adding  to  lo  c.  c.  of 
the  contents  two  drops  of  HCl,  then  boil  to  a  syrup  and  extract  with  ether. 
Dissolve  the  residue  obtained  upon  evaporation  of  the  ether  in  a  little  water 
and  test  for  lactic  acid  as  above. 

Butyric  and  Acetic  Acids.     See  "  odor.  " 
Total  Acidity,     Use  Phenolphthalein  as  an  indicator. 
Quantitative   Estimation   of    Free   HCl   and   the   Total 

Acidity.  A  decinormal  {-^-^)  solution  of  NaOH  is  employed. 
Each  c.  c.  used  represents  i  c.  c.  j'^^  HCl  in  the  given  amount 
(5-10  c.  c.)  stomach  contents,  i  c.  c.  ^^^HCl  contains  0.00365 
g.  HCl.  The  quantitative  values  of  free  HCl  and  the  total 
acidity  can  be  expressed  in  the  terms  of  %  HCl  or  as  the  num- 
ber of  c.c.  of  a  TTT  solution  NaOH  necessary  to  neutralize  100 
c.c.  gastric  contents.  20-50 c.c.  (o. 07^-0. 18%)  are  the  normal 
limits  for  free  HCl;  40-80  c.  c.  (o.i5%-o.3o%)  for  total  acidity. 


Fragments  of  Mucous  Membrane  are  often  found  in 
Achylia  Gastrica,  occasionally  in  cancer. 

Blood.  The  corpuscles  soon  disintegrate  or  are  digested. 
In  suspected  cases  use  Teichmann's  test,  being  careful  to  evap- 
orate the  contents  slowly. 

Pus.  The  cell  bodies  are  often  digested,  but  the  nuclei  are 
easily  recognized.  Pus  may  be  found  in  any  gastric  catarrh  ; 
often  in  the  fasting  stomachs  of  patients  with  ulcer  and  cancer. 
Large  amounts  indicate  Phlegmonous  Gastritis. 

Yeast  and  Bacteria  are  usually  present  in  small  amounts. 
In  dilatation  of  the  stomach  they  are  abundant. 


18 


Faeces. 

Amount  and  frequency  of  dejections.  Reaction.  Consist- 
ency and  form.  Color.  Odor.  Undigested  food ;  muscle, 
elastic  fibres,  fat,  starch,  casein,  vegetable  fibres.  Mucus. 
Blood.  Pus.  Tubercle  Bacilli.  Intestinal  Parasites.  Frag- 
ments of  new  growth.     Crystals. 


Amount  and  Frequency.  Dejections  vary  according  to 
character  of  food  and  habit;  "weight  is  normally  120-250  g. 
In  starvation  they  are  reduced  to  a  minimum.  Stools  may  he 
numerous  but  without  faecal  matter.  In  diarrhcea  from  the 
lower  colon  (dysentery)  — small,  frequent  motions  ;  in  that  of  the 
small  intestine  or  upper  colon  — large,  but  seldom. 

Consistency  and  Form.  The  longer  the  stools  remain  in 
the  rectum,  the  harder  and  dryer  they  become. 

Reaction.  Normally  neutral  or  faintly  acid  or  alkaline. 
Superficial  reaction  often  different  from  that  of  central  portion. 
Cholera  and  typhoid  stools  react  alkaline.  Carbohydrate  and 
milk  diets  give  acid  reaction. 

Color.  Normal  brown  color  due  to  urobilin.  Infants'  stools 
are  bright  or  golden  yellow  because  of  bilirubin;  on  standing 
they  may  soon  change  their  color.     Color  varies  with, — 

1.  Food  —  light  with  milk;  dark  with  blackberries,  red 
wine,  etc. ;  green  with  green  vegetables. 

2.  Drugs  —  green,  calomel;  black,  bismuth;  black,  iron, — 
though  perhaps  only  on  standing. 

3.  Blood.  If  originating  in  stomach  500  c.  c.  are  necessary 
to  give  characteristic  color. 

4.  Bile  —  clay -colored  from  diminished  secretion  or  obstruc- 
tion of  flow  of  bile.  Clay  color  is  also  due  to  unabsorbed  fat. 
Green  color  of  stools  depending  on  bile  is  pathological. 

The  test  for  bile  in  the  stools  is  complicated,  and,  except 
with  experts,  a  negative  result  is  of  little  value. 

Odor.     A  foul  odor  indicates  intestinal  putrefaction. 

Mucus  is  always  pathological  and  if  visible  in  the  stools 
means  catarrh  of  the  colon,  except  in  cases  of  colica  mucosa  in 

19 


which    there  is  a  nervous  hypersecretion  of    mucus.     It  may 
occur,  — 

1.  As  a  thick  coating. 

2.  Intimately  mixed. 

3.  Forming  the  whole  stool. 

4.  As  small  soft  bodies,  yellow  to  brown  in  color,  just 
visible  or  even  as  large  as  a  pea,  occurring  singly  or  in  large 
numbers. 

Blood.  The  higher  the  origin  the  more  it  is  changed  in 
color.  Tarry  or  "tea-like"  stools  in  gastric  haemorrhages. 
Confirm  by  Teichmann's  test,  not  confusing  the  haemin  crystals 
with  bismuth  crystals. 

Pus.  Large  amounts  come  from  abscesses  and  ulcers, 
small  amounts  may  come  from  catarrh.  The  pus  corpuscles 
soon  disintegrate  and  are  seen  with  difficulty. 

Tubercle  Bacilli. 

Undigested  Food.  Muscle  fibres  are  seen  in  every  stool,  but 
their  striae  are  poorly  marked  and  the  ends  are  rounded ;  elas- 
tic fibres  come  from  a  meat  diet.  Starch  is  never  seen  in  normal 
stools  and  seldom  in  diarrhoea.  Fat:  as  soaps,  neutral  fat  or 
fatty  acids  appear  normally  in  the  stools  varying  with  the  diet. 
Fat  crystals  are  seen  more  than  fat  drops.  Casein :  curds  are 
frequently  seen  in  infants'  stools. 

Intestinal  Parasites.  Amoeba  Coli.  Round  worms.  Pin 
worms.  Tapeworms: — pork  (Taenia  Solium.  This  worm  has 
hooklets  about  the  head.) ;  beef  (Taenia  mediocanellata  or  sag- 
inata)  ;  bothriocephalus  latus. 

Fragments  of  new  gro"wth.  Well  obtained  by  repeated 
enemata. 

Crystals.  Not  of  significance:  triple  phosphate,  neutral 
calcium  phosphate,  calcium  oxalate,  yellow  pigmented  calcium 
salts  of  fatty  acids,  cholesterin,  Charcot-Leyden  crystals. 


Apparatus  and  Chemical  Reagents. 


Stethoscope. 

Microscope  with  oil  immersion. 

Centrifugal  Machine. 

Blood  Counter. 

Tallqvist's  Haemoglobin  Scale. 

Blood  Oven. 

Cover  glasses  and  slides. 

Forceps. 


Nitric  Acid  —  cone. 
Glacial  Acetic  Acid. 
Dilute  Acetic  Acid. 
Sulphanilic  Acid  in  HCl, 
(saturated  solution.) 
Sodium  Nitrite  0.5%. 
Ammonium  Hydrate. 


Burette. 

Graduate. 

Specific  Gravity  Bulb. 

Squibb's  Urea  Apparatus. 

Test  Tubes. 

Red  and  blue  litmus. 

Congo  paper. 


Sodium  Hydrate. 
Sodium  Nitro-prusside. 
Ferric  Chloride,  (strong 

aqueous  solution). 
Iodine  Solution  (Tr.  Iodine, 

I ;  Alcohol,  8). 
Silver  Nitrate  Solution  i  :  8. 


Fehling's  Solution.  Dissolve  34.64  g.  pure  CuSoj,  in  water 
and  make  up  to  500  c.  c.  Dissolve  173  g.  Rochelle  Salts 
and  60  g.  Sodium  Hydrate  each  in  200  c.  c.  water  and 
mix,  and  then  make  up  also  to  500  c.  c.  5  c.  c.  of  each  sol. 
are  used  for  the  test. 

Bromine  Solution  for  Urea:  Bromine,  30  g. ;  Sodium  Bromide, 
30  g. ;  Water,  240  c.  c. 

Sodium  Hydrate  Solution  for  Urea:  NaOH,  loo.og. ;  Water, 
250  c.  c. 

IKI  Solution:  Iodine,  i  g.;  Potassium  Iodide, 2 g.;  Water,  300  c.c. 

Bismarck  brown,  (saturated  aqueous  solution). 

Alcohol  95%. 

Ehrlich's  Triple  Stain. 

Loflfler's  Methylene-blue. 

Ziehl's  Carbol-fuchsin. 

Czapelewski's  Solution,  NaCl,  1.25  g.;  HCl,  1.25  g.;  95%  Alcohol, 
250  c.  c. ;  Distilled  Water,  50  c.  c. 


21 


Methyleneblue  (saturated  aqueous  solution). 

Anilin-oil-gentian-violet  solution. 

Sodium  Chloride,  2%. 

Giinzburg's    Reagent.       Phloroglucin,    2    g. ;    Vanillin,    i     g. 

Alcohol,  30  g. 
Phenolphthalein. 
Tincture  Iodine. 
Ether. 


22 


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This  book  is  due  on  the  date  indicated  below,  or  at  the 
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the  Librarian  in  charge. 

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RC71 

^O^                          1900 
Harvard  Universitv.  Medical  

School . 

Theory  and  practice,  1900-1901. 


7/ 

/9oa 


